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Bloem AEM, Houben-Wilke S, Mostard RLM, Stoot N, Janssen DJA, Franssen FME, Custers JWH, Spruit MA. Respiratory and non-respiratory symptoms in patients with IPF or sarcoidosis and controls. Heart Lung 2023; 61:136-146. [PMID: 37269615 DOI: 10.1016/j.hrtlng.2023.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 05/06/2023] [Accepted: 05/20/2023] [Indexed: 06/05/2023]
Abstract
INTRODUCTION Besides dyspnoea and cough, patients with idiopathic pulmonary fibrosis (IPF) or sarcoidosis may experience distressing non-respiratory symptoms, such as fatigue or muscle weakness. However, whether and to what extent symptom burden differs between patients with IPF or sarcoidosis and individuals without respiratory disease remains currently unknown. OBJECTIVES To study the respiratory and non-respiratory burden of multiple symptoms in patients with IPF or sarcoidosis and to compare the symptom burden with individuals without impaired spirometric values, FVC and FEV1 (controls). METHODS Demographics and symptoms were assessed in 59 patients with IPF, 60 patients with sarcoidosis and 118 controls (age ≥18 years). Patients with either condition were matched to controls by sex and age. Severity of 14 symptoms was assessed using a Visual Analogue Scale. RESULTS 44 patients with IPF (77.3% male; age 70.6±5.5 years) and 44 matched controls, and 45 patients with sarcoidosis (48.9% male; age 58.1±8.6 year) and 45 matched controls were analyzed. Patients with IPF scored higher on 11 symptoms compared to controls (p<0.05), with the largest differences for dyspnoea, cough, fatigue, muscle weakness and insomnia. Patients with sarcoidosis scored higher on all 14 symptoms (p<0.05), with the largest differences for dyspnoea, fatigue, cough, muscle weakness, insomnia, pain, itch, thirst, micturition (night, day). CONCLUSIONS Generally, respiratory and non-respiratory symptom burden is significantly higher in patients with IPF or sarcoidosis compared to controls. This emphasizes the importance of awareness for respiratory and non-respiratory symptom burden in IPF or sarcoidosis and the need for additional research to study the underlying mechanisms and subsequent interventions.
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Affiliation(s)
- Ada E M Bloem
- University of Applied Sciences Utrecht, Institute of Movement Studies, Faculty of Health Care, Utrecht, the Netherlands; ILD Centre of Excellence, Department of Pulmonology, St. Antonius Hospital, Nieuwegein, the Netherlands.
| | | | - Rémy L M Mostard
- Department of Respiratory Medicine, Zuyderland Medical Center Heerlen, Heerlen/Sittard-Geleen, the Netherlands; Department of Respiratory Medicine, Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands
| | - Naomi Stoot
- Department of Respiratory Medicine, Zuyderland Medical Center Heerlen, Heerlen/Sittard-Geleen, the Netherlands
| | - Daisy J A Janssen
- Department of Research and Development, CIRO+, Horn, the Netherlands; Department of Health Services Research, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
| | - Frits M E Franssen
- Department of Research and Development, CIRO+, Horn, the Netherlands; Department of Respiratory Medicine, Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands; NUTRIM, School of Nutrition and Translational Research in Metabolism, Faculty of Health, Medicine and Life Sciences, Maastricht, the Netherlands
| | - Jan W H Custers
- University of Applied Sciences Utrecht, Institute of Movement Studies, Faculty of Health Care, Utrecht, the Netherlands
| | - Martijn A Spruit
- Department of Research and Development, CIRO+, Horn, the Netherlands; Department of Respiratory Medicine, Maastricht University Medical Center (MUMC+), Maastricht, the Netherlands; NUTRIM, School of Nutrition and Translational Research in Metabolism, Faculty of Health, Medicine and Life Sciences, Maastricht, the Netherlands
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Ferreira DH, Ekström M, Huang C, Currow DC. Minimally Clinically Important Improvements (MCII) and Worsening (MCIW) in Symptoms. J Pain Symptom Manage 2022; 64:e107-e108. [PMID: 35429604 DOI: 10.1016/j.jpainsymman.2022.04.169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 04/06/2022] [Indexed: 11/23/2022]
Affiliation(s)
- Diana H Ferreira
- Faculty of Science, Medicine and Health (D.H.F., D.C.C.), University of Wollongong, Wollongong, New South Wales, Australia; Department of Clinical Sciences, Division of Respiratory Medicine & Allergology (M.E.), Lund University, Lund, Sweden; Institute for Clinical and Applied Health Research, University of Hull (C.H.), Hull, United Kingdom.
| | - Magnus Ekström
- Faculty of Science, Medicine and Health (D.H.F., D.C.C.), University of Wollongong, Wollongong, New South Wales, Australia; Department of Clinical Sciences, Division of Respiratory Medicine & Allergology (M.E.), Lund University, Lund, Sweden; Institute for Clinical and Applied Health Research, University of Hull (C.H.), Hull, United Kingdom
| | - Chao Huang
- Faculty of Science, Medicine and Health (D.H.F., D.C.C.), University of Wollongong, Wollongong, New South Wales, Australia; Department of Clinical Sciences, Division of Respiratory Medicine & Allergology (M.E.), Lund University, Lund, Sweden; Institute for Clinical and Applied Health Research, University of Hull (C.H.), Hull, United Kingdom
| | - David C Currow
- Faculty of Science, Medicine and Health (D.H.F., D.C.C.), University of Wollongong, Wollongong, New South Wales, Australia; Department of Clinical Sciences, Division of Respiratory Medicine & Allergology (M.E.), Lund University, Lund, Sweden; Institute for Clinical and Applied Health Research, University of Hull (C.H.), Hull, United Kingdom
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Kochovska S, Huang C, Johnson MJ, Agar MR, Fallon MT, Kaasa S, Hussain JA, Portenoy RK, Higginson IJ, Currow DC. Intention-to-Treat Analyses for Randomized Controlled Trials in Hospice/Palliative Care: The Case for Analyses to be of People Exposed to the Intervention. J Pain Symptom Manage 2020; 59:637-645. [PMID: 31707068 DOI: 10.1016/j.jpainsymman.2019.10.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 08/19/2019] [Accepted: 10/25/2019] [Indexed: 10/25/2022]
Abstract
CONTEXT Minimizing bias in randomized controlled trials (RCTs) includes intention-to-treat analyses. Hospice/palliative care RCTs are constrained by high attrition unpredictable when consenting, including withdrawals between randomization and first exposure to the intervention. Such withdrawals may systematically bias findings away from the new intervention being evaluated if they are considered nonresponders. OBJECTIVES This study aimed to quantify the impact within intention-to-treat principles. METHODS A theoretical model was developed to assess the impact of withdrawals between randomization and first exposure on study power and effect sizes. Ten reported hospice/palliative care studies had power recalculated accounting for such withdrawal. RESULTS In the theoretical model, when 5% of withdrawals occurred between randomization and first exposure to the intervention, change in power was demonstrated in binary outcomes (2.0%-2.2%), continuous outcomes (0.8%-2.0%), and time-to-event outcomes (1.6%-2.0%), and odds ratios were changed by 0.06-0.17. Greater power loss was observed with larger effect sizes. Withdrawal rates were 0.9%-10% in the 10 reported RCTs, corresponding to power losses of 0.1%-2.2%. For studies with binary outcomes, withdrawal rates were 0.3%-1.2% changing odds ratios by 0.01-0.22. CONCLUSION If blinding is maintained and all interventions are available simultaneously, our model suggests that excluding data from withdrawals between randomization and first exposure to the intervention minimizes one bias. This is the safety population as defined by the International Committee on Harmonization. When planning for future trials, minimizing the time between randomization and first exposure to the intervention will minimize the problem. Power should be calculated on people who receive the intervention.
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Affiliation(s)
- Slavica Kochovska
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | | | - Miriam J Johnson
- The University of Hull, Hull, UK; Wolfson Palliative Care Research Centre, University of Hull, Hull, UK
| | - Meera R Agar
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Marie T Fallon
- Cancer Research UK Edinburgh Centre, MRC Institute of Genetics and Molecular Medicine, The University of Edinburgh, Edinburgh, UK
| | - Stein Kaasa
- Institute of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim (NTNU), Trondheim, Norway
| | - Jamilla A Hussain
- Wolfson Palliative Care Research Centre, University of Hull, Hull, UK
| | - Russell K Portenoy
- MJHS Institute for Innovation in Palliative Care, MJHS Hospice and Palliative Care, New York, New York, USA
| | - Irene J Higginson
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK
| | - David C Currow
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia; The University of Hull, Hull, UK; Wolfson Palliative Care Research Centre, University of Hull, Hull, UK.
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Ekström M, Williams M, Johnson MJ, Huang C, Currow DC. Agreement Between Breathlessness Severity and Unpleasantness in People With Chronic Breathlessness: A Longitudinal Clinical Study. J Pain Symptom Manage 2019; 57:715-723.e5. [PMID: 30639756 DOI: 10.1016/j.jpainsymman.2019.01.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 12/31/2018] [Accepted: 01/02/2019] [Indexed: 11/25/2022]
Abstract
CONTEXT Chronic breathlessness is a cardinal symptom in cardiopulmonary disease where both overall intensity or severity (S) and unpleasantness (U) are commonly quantified. OBJECTIVE We aimed to evaluate agreement between breathlessness severity and unpleasantness over eight days in patients with chronic breathlessness. METHODS Longitudinal analysis of 265 patients with chronic breathlessness who rated current overall breathlessness severity and unpleasantness on a 0-100 mm visual analogue scale (VAS) in the morning and evening over eight days. A total of 3630 paired overall severity-unpleasantness (S-U) differences were analyzed; median 15 (IQR 13-16) per patient. Agreement was evaluated using Bland-Altman plots. Associations of the difference between severity and unpleasantness (S-U difference) with clinical factors and perceived quality of life were analyzed using multilevel linear regression adjusted for confounders. RESULTS Over eight days, severity and unpleasantness scores were highly correlated, had similar variability, and varied more between patients than within patients. The mean S-U difference was small at 2.1 mm. Agreement between overall severity and unpleasantness was similar or higher than expected from the variability in individual scores. The S-U difference was similar across evaluated factors including age, sex, diagnosis, morning/evening assessment, modified Medical Research Council breathlessness score, morphine treatment, and presence of different sensory qualities of breathlessness. Higher overall severity and unpleasantness associated with worse perceived quality of life in a similar way. CONCLUSION In patients with chronic breathlessness over eight days, overall severity and unpleasantness of breathlessness were comparable and associated to other clinical factors in a similar manner.
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Affiliation(s)
- Magnus Ekström
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Respiratory Medicine and Allergology, Lund, Sweden; ImPaCCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia.
| | - Marie Williams
- School of Health Sciences, University of South Australia, Adelaide, Australia
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, UK
| | - Chao Huang
- Hull York Medical School, Institute for Clinical and Applied Health Research, University of Hull, UK
| | - David C Currow
- ImPaCCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
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Takahashi K, Kondo M, Ando M, Shiraki A, Nakashima H, Wakayama H, Kataoka K, Yamamoto M, Sugino Y, Nishikawa M, Imaizumi K, Kojima E, Sumida A, Takeyama Y, Saito H, Hasegawa Y. Effects of Oral Morphine on Dyspnea in Patients with Cancer: Response Rate, Predictive Factors, and Clinically Meaningful Change (CJLSG1101). Oncologist 2019; 24:e583-e589. [PMID: 30659079 DOI: 10.1634/theoncologist.2018-0468] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 11/07/2018] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Although the efficacy of parenteral morphine for alleviating dyspnea has been previously demonstrated in several studies, little is known regarding the efficacy of oral morphine for dyspnea among patients with cancer, including its response rate and predictive factors of effectiveness. Therefore, the aim of this study was to clarify the effectiveness of oral morphine on dyspnea in patients with cancer and elucidate the predictive factors of its effectiveness. SUBJECTS, MATERIALS, AND METHODS In this multicenter prospective observational study, we investigated the change in dyspnea intensity in patients with cancer before and after the administration of oral morphine by using a visual analog scale (VAS). We also administered a self-assessment questionnaire to determine whether the patients believed oral morphine was effective. RESULTS Eighty patients were enrolled in the study, and 71 of these patients were eligible. The least square mean of the VAS scores for dyspnea intensity was 53.5 at baseline, which decreased significantly to 44.7, 40.8, and 35.0 at 30, 60, and 120 minutes after morphine administration, respectively. Fifty-four patients (76.1%) reported that oral morphine was effective on the self-assessment questionnaire. Among the background factors, a high score for "sense of discomfort" on the Cancer Dyspnea Scale (CDS) and a smoking history of fewer pack-years were associated with greater effectiveness. CONCLUSION Oral morphine was effective and feasible for treating cancer-related dyspnea. A higher score for "sense of discomfort" on the CDS and a smaller cumulative amount of smoking may be predictive factors of the effectiveness of oral morphine. IMPLICATIONS FOR PRACTICE This study demonstrated that oral morphine was effective in alleviating cancer-related dyspnea due to multiple factors including primary lung lesions, airway narrowing, and pleural effusion. Approximately 76% of patients reported that oral morphine was effective. A higher score for "sense of discomfort" on the Cancer Dyspnea Scale and a lower cumulative amount of smoking may be predictive factors for the effectiveness of oral morphine. Interestingly, respiratory rates in patients who reported the morphine to be effective decreased significantly after oral morphine administration, unlike the respiratory rates in "morphine-ineffective" patients.
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Affiliation(s)
- Kosuke Takahashi
- Department of Respiratory Medicine, Aichi Cancer Center Aichi Hospital, Okazaki, Japan
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masashi Kondo
- Department of Respiratory Medicine, Fujita Health University School of Medicine, Toyoake, Japan
| | - Masahiko Ando
- Center for Advanced Medicine and Clinical Research, Nagoya University Hospital, Nagoya, Japan
| | - Akira Shiraki
- Department of Respiratory Medicine, Ogaki Municipal Hospital, Ogaki, Japan
| | - Harunori Nakashima
- Department of Respiratory Medicine, Ogaki Municipal Hospital, Ogaki, Japan
| | - Hisashi Wakayama
- Department of Respiratory Medicine, Nagoya Daini Red Cross Hospital, Nagoya, Japan
| | - Kensuke Kataoka
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto, Japan
| | - Masashi Yamamoto
- Department of Respiratory Medicine, Nagoya Ekisaikai Hospital, Nagoya, Japan
| | - Yasuteru Sugino
- Department of Respiratory Medicine, Toyota Memorial Hospital, Toyota, Japan
| | - Mitsunori Nishikawa
- Department of Palliative Care, National Center for Geriatrics and Gerontology, Obu, Japan
| | - Kazuyoshi Imaizumi
- Department of Respiratory Medicine, Fujita Health University School of Medicine, Toyoake, Japan
| | - Eiji Kojima
- Department of Respiratory Medicine, Komaki Municipal Hospital, Komaki, Japan
| | - Atsushi Sumida
- Department of Respiratory Medicine, Tsushima City Hospital, Tsushima, Japan
| | - Yoshihiro Takeyama
- Department of Respiratory Medicine, Toyohashi Municipal Hospital, Toyohashi, Japan
| | - Hiroshi Saito
- Department of Respiratory Medicine, Aichi Cancer Center Aichi Hospital, Okazaki, Japan
| | - Yoshinori Hasegawa
- Department of Respiratory Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Yates H, Adamali HI, Maskell N, Barratt S, Sharp C. Visual analogue scales for interstitial lung disease: a prospective validation study. QJM 2018; 111:531-539. [PMID: 29788503 DOI: 10.1093/qjmed/hcy102] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Revised: 04/25/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Visual analogue scales (VAS) are simple symptom assessment tools which have not been validated in interstitial lung disease (ILD). Simple measures of ILD disease burden would be valuable for non-specialist clinicians monitoring disease away from ILD specialist centres. OBJECTIVE To validate VAS to assess change in dyspnoea, cough and fatigue in ILD, and to define the minimal clinically important difference (MCID) for change in these. METHODS Patients of 64 with ILD completed VAS for dyspnoea, cough and fatigue. Baseline King's Brief ILD questionnaire (K-BILD) scores, lung function and 6-min walk test results were collected. Tests were repeated 3-6 months later, in addition to a seven-point Likert scale. The MCID was estimated using median change in VAS in patients who reported 'small but just worthwhile change' in symptoms at follow-up. Methods were repeated in a validation cohort of 31 ILD patients to confirm findings. RESULTS VAS scores were significantly higher for patients who reported a 'small but just worthwhile change' in symptoms vs. 'no change' or 'not worthwhile change' (P < 0.01). The MCID for VAS Dyspnoea was estimated as 22.0 mm and 14.5 mm for VAS Fatigue. These results were reproducible in the validation cohort. Results were not significant for VAS Cough. Change in VAS Dyspnoea correlated with change in K-BILD (r = -0.51, P < 0.01), forced vital capacity (r = -0.32, P = 0.01) and 6-min walking distance (r = -0.37, P = 0.01). CONCLUSION The VAS is valid for assessing change in dyspnoea and fatigue in ILD. The MCID is estimated as 22.0 mm for dyspnoea and 14.5 mm for fatigue. This could be used to monitor disease in settings away from ILD specialist review. MESH DESCRIPTORS Lung Diseases, Interstitial, Dyspnoea, Fatigue, Cough.
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Affiliation(s)
- H Yates
- Respiratory and Sleep Physiology, Royal Brompton and Harefield NHS Trust, London, UK
| | - H I Adamali
- Bristol ILD Service, North Bristol NHS Trust, Bristol, UK
| | - N Maskell
- Academic Respiratory Unit, University of Bristol, Southmead Hospital, Bristol, UK
| | - S Barratt
- Bristol ILD Service, North Bristol NHS Trust, Bristol, UK
| | - C Sharp
- Respiratory Department, Gloucestershire Hospitals NHS Foundation Trust, Gloucester Royal Hospital, Great Western Road, Gloucester, UK
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Janowiak P, Krajnik M, Podolec Z, Bandurski T, Damps-Konstańska I, Sobański P, Currow DC, Jassem E. Dosimetrically administered nebulized morphine for breathlessness in very severe chronic obstructive pulmonary disease: a randomized, controlled trial. BMC Pulm Med 2017; 17:186. [PMID: 29228935 PMCID: PMC5725796 DOI: 10.1186/s12890-017-0535-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 11/29/2017] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Systemic morphine has evidence to support its use for reducing breathlessness in patients with severe chronic obstructive pulmonary disease (COPD). The effectiveness of the nebulized route, however, has not yet been confirmed. Recent studies have shown that opioid receptors are localized within epithelium of human trachea and large bronchi, a target site for a dosimetric nebulizer. The aim of this study was to compare any clinical or statistical differences in breathlessness intensity between nebulized 2.0% morphine and 0,9% NaCl in patients with very severe COPD. METHODS The study was a double-blind, controlled, cross-over trial. Participants received morphine or NaCl during two 4-day periods. Sequence of periods was randomized. The primary outcome measure was reduction of breathlessness intensity now by ≥20 mm using a 100 mm visual analogue scale (VAS) at baseline, 15, 30, 60, 120, 180 and 240 min after daily administration, during normal activities. RESULTS Ten of 11 patients included completed the study protocol. All patients experienced clinically and statistically significant (p < 0.0001) breathlessness reduction during morphine nebulization. Mean VAS changes for morphine and 0.9% NaCl periods were 25.4 mm (standard deviation (SD): 9.0; median: 23,0; range: 14.0 to 41,5; confidence interval (CI): 95%) and 6.3 mm (SD: 7.8; median: 6.8; range: -11,5 to 19,5; CI: 95%), respectively. No treatment emergent adverse effects were noted. DISCUSSION Our study showed superiority of dosimetrically administered nebulized morphine compared to NaCl in reducing breathlessness. This may have been achieved through morphine's direct action on receptors in large airways, although a systemic effect from absorption through the lungs cannot be excluded. TRIAL REGISTRATION Retrospectively registered (07.03.2017), ISRCTN14865597.
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Affiliation(s)
- Piotr Janowiak
- Department of Pneumonology and Allergology, Medical University of Gdańsk, Dębinki 7, 80-211 Gdańsk, Poland
| | - Małgorzata Krajnik
- Department of Palliative Care, Nicolaus Copernicus University, Collegium Medicum in Bydgoszcz, M. Curie Skłodowskiej 9, 85-094 Bydgoszcz, Poland
| | - Zygmunt Podolec
- Department of Aerosology and Aerosol Bioengineering, Research and Development Centre of MEDiNET, Juliusza Lea 114, 30-133 Kraków, Poland
| | - Tomasz Bandurski
- Department of Radiology Informatics and Statistics, Medical University of Gdańsk, Tuwima 15, 80-210 Gdańsk, Poland
| | - Iwona Damps-Konstańska
- Department of Pneumonology and Allergology, Medical University of Gdańsk, Dębinki 7, 80-211 Gdańsk, Poland
| | - Piotr Sobański
- Palliativzentrum Hildegard, Sankt Alban-Ring 151, 4020 Basel, Switzerland
- Gynaecological Cancer Center, University Hospital Basel, Spitalstrasse 21, 4031 Basel, Switzerland
| | - David C. Currow
- Faculty of Health, University of Technology Sydney, PO Box 123, Broadway, NSW 2007 Australia
| | - Ewa Jassem
- Department of Pneumonology and Allergology, Medical University of Gdańsk, Dębinki 7, 80-211 Gdańsk, Poland
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Effect of Lee Silverman Voice Treatment (LSVT LOUD®) on swallowing and cough in Parkinson's disease: A pilot study. J Neurol Sci 2017; 383:180-187. [DOI: 10.1016/j.jns.2017.11.015] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Revised: 10/23/2017] [Accepted: 11/14/2017] [Indexed: 02/02/2023]
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Johnson MJ, Yorke J, Hansen-Flaschen J, Lansing R, Ekström M, Similowski T, Currow DC. Towards an expert consensus to delineate a clinical syndrome of chronic breathlessness. Eur Respir J 2017; 49:49/5/1602277. [PMID: 28546269 DOI: 10.1183/13993003.02277-2016] [Citation(s) in RCA: 181] [Impact Index Per Article: 25.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 02/14/2017] [Indexed: 12/30/2022]
Abstract
Breathlessness that persists despite treatment for the underlying conditions is debilitating. Identifying this discrete entity as a clinical syndrome should raise awareness amongst patients, clinicians, service providers, researchers and research funders.Using the Delphi method, questions and statements were generated via expert group consultations and one-to-one interviews (n=17). These were subsequently circulated in three survey rounds (n=34, n=25, n=31) to an extended international group from various settings (clinical and laboratory; hospital, hospice and community) and working within the basic sciences and clinical specialties. The a priori target agreement for each question was 70%. Findings were discussed at a multinational workshop.The agreed term, chronic breathlessness syndrome, was defined as breathlessness that persists despite optimal treatment of the underlying pathophysiology and that results in disability. A stated duration was not needed for "chronic". Key terms for French and German translation were also discussed and the need for further consensus recognised, especially with regard to cultural and linguistic interpretation.We propose criteria for chronic breathlessness syndrome. Recognition is an important first step to address the therapeutic nihilism that has pervaded this neglected symptom and could empower patients and caregivers, improve clinical care, focus research, and encourage wider uptake of available and emerging evidence-based interventions.
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Affiliation(s)
| | - Janelle Yorke
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | - John Hansen-Flaschen
- Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Robert Lansing
- Harvard Medical School, Beth Israel Hospital, Boston, MA, USA
| | - Magnus Ekström
- Dept of Clinical Sciences, Division of Respiratory Medicine & Allergology, Lund University, Lund, Sweden
| | - Thomas Similowski
- Service de Pneumologie et Reanimation Medicale, Groupe Hospitalier Pitie-Salpetriere Charles Foix, Paris, France
| | - David C Currow
- Hull York Medical School, University of Hull, Hull, UK.,University of Technology Sydney, Sydney, Australia
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Currow DC, Abernethy AP, Fallon M, Portenoy RK. Repurposing Medications for Hospice/Palliative Care Symptom Control Is No Longer Sufficient: A Manifesto for Change. J Pain Symptom Manage 2017; 53:533-539. [PMID: 28042066 DOI: 10.1016/j.jpainsymman.2016.10.358] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 10/11/2016] [Accepted: 10/20/2016] [Indexed: 10/20/2022]
Abstract
The World Health Organization essential medications list for hospice/palliative care reflects that, with the judicious use of currently available medications, the majority of symptoms can be lessened, and some controlled completely. Even with optimal use of current medications, symptom control is still unacceptable for many people. Currently available medications offer great benefit to a minority of patients, some benefit to an additional group, and no benefit or harms to others. In symptom control, development of new drugs is advancing at a glacial pace, contrasting to the rapid advances seen in many other disciplines. Specialists in palliative care should agree on several principles consequently: 1) Access to symptom-control drugs codified in the World Health Organization Essential Medicines list deserves the strongest support from national policies and professional guidelines, especially in resource-challenged countries. 2) The optimal use of currently available symptom-control drugs cannot yield acceptably high rates of net benefits. 3) There is a compelling need to identify patient subgroups that are likely to benefit from available medications and provide rigorous empirical support for indications, dosing, and route of administration for clinical practice. 4) New therapies are needed requiring an accelerated effort to investigate further the pathophysiology, neurobiology, and pharmacogenetics of distressing symptoms, and factors contributing to variations in drug response. This development requires a lengthy lead time. 5) Smarter ways to promote new knowledge into practice are needed as no drug will be suitable for all patients. We need to improve clinical characterization and biomarker technology to bring the best drugs to the right patients every time.
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Affiliation(s)
- David C Currow
- Discipline, Palliative and Supportive Services, Flinders University, Adelaide, Australia.
| | - Amy P Abernethy
- Discipline, Palliative and Supportive Services, Flinders University, Adelaide, Australia; Division of Medical Oncology, Department of Medicine, Duke University Medical Centre, Durham, North Carolina, USA
| | - Marie Fallon
- St Columba's Hospice Chair of Palliative Medicine, Edinburgh Cancer Research Centre, University of Edinburgh, Edinburgh, Scotland, UK
| | - Russell K Portenoy
- MJHS Institute for Innovation in Palliative Care, New York, New York, USA
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11
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Predictors of response to corticosteroids for dyspnea in advanced cancer patients: a preliminary multicenter prospective observational study. Support Care Cancer 2016; 25:1169-1181. [DOI: 10.1007/s00520-016-3507-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 11/21/2016] [Indexed: 12/19/2022]
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Stefan MS, Priya A, Martin B, Pekow PS, Rothberg MB, Goldberg RJ, DiNino E, Lindenauer PK. How well do patients and providers agree on the severity of dyspnea? J Hosp Med 2016; 11:701-707. [PMID: 27130579 PMCID: PMC6423510 DOI: 10.1002/jhm.2600] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 03/28/2016] [Accepted: 04/05/2016] [Indexed: 11/10/2022]
Abstract
BACKGROUND Understanding the severity of patients' dyspnea is critical to avoid under- or overtreatment of patients with acute cardiopulmonary conditions. OBJECTIVE To evaluate the agreement between dyspnea assessment by patients and healthcare providers and to explore which factors contribute to discordance in assessment. DESIGN, SETTINGS AND PARTICIPANTS Prospective study of patients hospitalized for acute cardiopulmonary diseases at an urban teaching hospital. INTERVENTION AND MEASUREMENTS A numerical rating scale (0-10) was used to assess dyspnea severity as perceived by patients and assessed by providers. Agreement was defined as a score within ±1 between patient and healthcare provider; differences of ≥2 points were considered over- or underestimations. The relationship between patient self-perceived dyspnea severity and provider rating was assessed using a weighted kappa coefficient. RESULTS Of the 138 patients enrolled, 33% had a diagnosis of heart failure, 30% chronic obstructive pulmonary disease, and 13% pneumonia; median age was 72 years, and 57% were women. In all, 96 patient-physician and 138 patient-nurses pairs were included in the study. The kappa coefficient for agreement was 0.11 (95% confidence interval [CI]: 0.01 to 0.21) between patients and physicians and 0.18 (95% CI: 0.12 to 0.24) between patients and nurses. Physicians underestimated patients' dyspnea 37.9% of the time and overestimated it 25.8% of the time, whereas nurses underestimated it 43.5% of the time and overestimated it 12.4% of the time. Admitting diagnosis was the only patient factor associated with discordance. CONCLUSIONS Agreement between patient perception of dyspnea and healthcare providers' assessment is low. Future studies should prospectively test whether routine assessment of dyspnea results in better patient outcomes. Journal of Hospital Medicine 2016;11:701-707. © 2016 Society of Hospital Medicine.
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Affiliation(s)
- Mihaela S Stefan
- Center for Quality of Care Research, Baystate Medical Center, Springfield, Massachusetts.
- Division of General Internal Medicine, Baystate Medical Center, Springfield, Massachusetts.
- Tufts Clinical and Translational Science Institute, Boston, Massachusetts.
- Tufts University School of Medicine, Boston, Massachusetts.
| | - Aruna Priya
- Center for Quality of Care Research, Baystate Medical Center, Springfield, Massachusetts
| | | | - Penelope S Pekow
- Center for Quality of Care Research, Baystate Medical Center, Springfield, Massachusetts
- School of Public Health & Health Sciences, University of Massachusetts-Amherst, Amherst, Massachusetts
| | | | - Robert J Goldberg
- Division of Epidemiology of Chronic Diseases & Vulnerable Populations and Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Ernest DiNino
- Division of Pulmonary and Critical Care Medicine, Baystate Medical Center, Springfield, Massachusetts
| | - Peter K Lindenauer
- Center for Quality of Care Research, Baystate Medical Center, Springfield, Massachusetts
- Division of General Internal Medicine, Baystate Medical Center, Springfield, Massachusetts
- Tufts Clinical and Translational Science Institute, Boston, Massachusetts
- Tufts University School of Medicine, Boston, Massachusetts
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Ferreira DH, Silva JP, Quinn S, Abernethy AP, Johnson MJ, Oxberry SG, Currow DC. Blinded Patient Preference for Morphine Compared to Placebo in the Setting of Chronic Refractory Breathlessness--An Exploratory Study. J Pain Symptom Manage 2016; 51:247-54. [PMID: 26598037 DOI: 10.1016/j.jpainsymman.2015.10.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 09/28/2015] [Accepted: 10/06/2015] [Indexed: 12/14/2022]
Abstract
CONTEXT Patients' preference for morphine therapy has received little attention in the setting of chronic refractory breathlessness. However, this is one important factor in considering longer term therapy. OBJECTIVES The aim of this secondary analysis was to explore blinded patient preference of morphine compared to placebo for this indication and to define any predictors of preference. METHODS Data were pooled from three randomized, double-blind, crossover, placebo-controlled studies of morphine (four days each) in chronic refractory breathlessness. Blinded patient preferences were chosen at the end of each study. A multivariable regression model was used to establish patient predictors of preference. RESULTS Sixty-five participants provided sufficient data (60 men; median age 74 years; heart failure 55%, chronic obstructive pulmonary disease 45%; median Eastern Cooperative Oncology Group performance status 2). Forty-three percent of participants preferred morphine (32% placebo and 25% no preference). Morphine preference and younger age were strongly associated: odds ratio = 0.85, 95% confidence interval 0.78-0.93; P < 0.001). There was also an inverse association between morphine preference and sedation (odds ratio = 0.77, 95% confidence interval 0.60-0.99; P < 0.05). An inverse association was also seen between nausea and morphine preference in the univariate model only (P < 0.05). No association was seen between morphine preference and breathlessness intensity, either at baseline or change from baseline. CONCLUSION Participants preferred morphine over placebo for the relief of chronic refractory breathlessness. Morphine offers clinically important improvement, but net benefit can be easily outweighed by side effects, reducing net benefits. Side effects require aggressive management to allow more patients to realize benefits.
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Affiliation(s)
- Diana H Ferreira
- Department of Internal Medicine, Hospital de Egas Moniz-CHLO, Lisbon, Portugal; Department of Medical Oncology, Portuguese Institute of Oncology (IPO) of Lisbon Francisco Gentil EPE, Lisbon, Portugal
| | - José P Silva
- Department of Internal Medicine, Hospital de Egas Moniz-CHLO, Lisbon, Portugal; Department of Medical Oncology, Portuguese Institute of Oncology (IPO) of Lisbon Francisco Gentil EPE, Lisbon, Portugal.
| | - Stephen Quinn
- School of Medicine, Flinders University, Bedford Park, South Australia, Australia
| | - Amy P Abernethy
- Discipline, Palliative and Supportive Services, Flinders University, Bedford Park, South Australia, Australia; Department of Medicine, Duke University Medical Centre, Durham, North Carolina, USA
| | - Miriam J Johnson
- Palliative Medicine, Hull York Medical School, University of Hull, Hull, United Kingdom
| | | | - David C Currow
- Discipline, Palliative and Supportive Services, Flinders University, Bedford Park, South Australia, Australia
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Mishra EK, Corcoran JP, Hallifax RJ, Stradling J, Maskell NA, Rahman NM. Defining the minimal important difference for the visual analogue scale assessing dyspnea in patients with malignant pleural effusions. PLoS One 2015; 10:e0123798. [PMID: 25874452 PMCID: PMC4398419 DOI: 10.1371/journal.pone.0123798] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 03/06/2015] [Indexed: 11/18/2022] Open
Abstract
Background The minimal important difference (MID) is essential for interpreting the results of randomised controlled trials (RCTs). Despite a number of RCTs in patients with malignant pleural effusions (MPEs) which use the visual analogue scale for dyspnea (VASD) as an outcome measure, the MID has not been established. Methods Patients with suspected MPE undergoing a pleural procedure recorded their baseline VASD and their post-procedure VASD (24 hours after the pleural drainage), and in parallel assessed their breathlessness on a 7 point Likert scale. Findings The mean decrease in VASD in patients with a MPE reporting a ‘small but just worthwhile decrease’ in their dyspnea (i.e. equivalent to the MID) was 19mm (95% CI 14-24mm). The mean drainage volume required to produce a change in VASD of 19mm was 760ml. Interpretation The mean MID for the VASD in patients with a MPE undergoing a pleural procedure is 19mm (95% CI 14-24mm). Thus choosing an improvement of 19mm in the VASD would be justifiable in the design and analysis of future MPE studies.
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Affiliation(s)
- Eleanor K. Mishra
- Oxford Centre for Respiratory Medicine and Oxford Respiratory Trials Unit, Oxford Biomedical Research Centre, Churchill Hospital, Oxford, United Kingdom
- * E-mail:
| | - John P. Corcoran
- Oxford Centre for Respiratory Medicine and Oxford Respiratory Trials Unit, Oxford Biomedical Research Centre, Churchill Hospital, Oxford, United Kingdom
| | - Robert J. Hallifax
- Oxford Centre for Respiratory Medicine and Oxford Respiratory Trials Unit, Oxford Biomedical Research Centre, Churchill Hospital, Oxford, United Kingdom
| | - John Stradling
- Oxford Centre for Respiratory Medicine and Oxford Respiratory Trials Unit, Oxford Biomedical Research Centre, Churchill Hospital, Oxford, United Kingdom
| | | | - Najib M. Rahman
- Oxford Centre for Respiratory Medicine and Oxford Respiratory Trials Unit, Oxford Biomedical Research Centre, Churchill Hospital, Oxford, United Kingdom
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Oxberry SG, Torgerson DJ, Bland JM, Clark AL, Cleland JG, Johnson MJ. Short-term opioids for breathlessness in stable chronic heart failure: a randomized controlled trial. Eur J Heart Fail 2014; 13:1006-12. [DOI: 10.1093/eurjhf/hfr068] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Stephen G. Oxberry
- Department of Health Sciences; Hull York Medical School, York University; Heslington York YO10 5DD UK
| | - David J. Torgerson
- Department of Health Sciences; Hull York Medical School, York University; Heslington York YO10 5DD UK
| | - J. Martin Bland
- Department of Health Sciences; Hull York Medical School, York University; Heslington York YO10 5DD UK
| | - Andrew L. Clark
- Castle Hill Hospital; Academic Cardiology; 1st Floor Daisy Building, Castle Road Cottingham HU16 5JQ UK
| | - John G.F. Cleland
- Castle Hill Hospital; Academic Cardiology; 1st Floor Daisy Building, Castle Road Cottingham HU16 5JQ UK
| | - Miriam J. Johnson
- Hull York Medical School; University of Hull; Hertford Building, Cottingham Road Hull HU6 7RX UK
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Currow DC, Ekstrom M, Abernethy AP. Opioids for Chronic Refractory Breathlessness: Right Patient, Right Route? Drugs 2013; 74:1-6. [DOI: 10.1007/s40265-013-0162-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Johnson MJ, Bland JM, Oxberry SG, Abernethy AP, Currow DC. Clinically important differences in the intensity of chronic refractory breathlessness. J Pain Symptom Manage 2013; 46:957-63. [PMID: 23608121 DOI: 10.1016/j.jpainsymman.2013.01.011] [Citation(s) in RCA: 102] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2012] [Revised: 01/23/2013] [Accepted: 01/28/2013] [Indexed: 11/21/2022]
Abstract
CONTEXT Clinically important differences in chronic refractory breathlessness are ill defined but important in clinical practice and trial design. OBJECTIVES To estimate the clinical relevance of differences in breathlessness intensity using distribution and patient anchor methods. METHODS This was a retrospective data analysis from 213 datasets from four clinical trials for refractory breathlessness. Linear regression was used to explore the relationship between study effect size and change in breathlessness score (0-100mm visual analogue scale) and to estimate the change in score equivalent to small, moderate, and large effect sizes. Pooled individual blinded patient preference data from three randomized controlled trials were analyzed. The difference between the mean change in Day 4 minus baseline scores between preferred and non-preferred arms was calculated. RESULTS There was a strong relationship between change in score and effect size (P = 0.001; R(2) = 0.98). Values for small, moderate, and large effects were -5.5, -11.3, and -18.2mm. The participant preference change in score was -9mm (95% CI, -15.8, -2.1) (P = 0.008). CONCLUSION This larger dataset supports a clinically important difference of 10mm. Studies should be powered to detect this difference.
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Affiliation(s)
- Miriam J Johnson
- Palliative Medicine, Hull York Medical School, University of Hull, Hull, United Kingdom.
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Abstract
BACKGROUND People with asthma may show less tolerance to exercise due to worsening asthma symptoms during exercise or other reasons such as deconditioning as a consequence of inactivity. Some may restrict activities as per medical advice or family influence and this might result in reduced physical fitness. Physical training programs aim to improve physical fitness, neuromuscular coordination and self confidence. Subjectively, many people with asthma report that they are symptomatically better when fit, but results from trials have varied and have been difficult to compare because of different designs and training protocols. Also, as exercise can induce asthma, the safety of exercise programmes needs to be considered. OBJECTIVES To gain a better understanding of the effect of physical training on the respiratory and general health of people with asthma, from randomised trials. SEARCH METHODS We searched the Cochrane Airways Group Specialised Register of trials up to January 2013. SELECTION CRITERIA We included randomised trials of people over eight years of age with asthma who were randomised to undertake physical training or not. Physical training had to be undertaken for at least 20 minutes, two times a week, over a minimum period of four weeks. DATA COLLECTION AND ANALYSIS Two review authors independently assessed eligibility for inclusion and undertook risk of bias assessment for the included studies. MAIN RESULTS Twenty-one studies (772 participants) were included in this review with two additional 2012 studies identified as 'awaiting classification'. Physical training was well tolerated with no adverse effects reported. None of the studies mentioned worsening of asthma symptoms following physical training. Physical training showed marked improvement in cardiopulmonary fitness as measured by a statistically and clinically significant increase in maximum oxygen uptake (mean difference (MD) 4.92 mL/kg/min; 95% confidence interval (CI) 3.98 to 5.87; P < 0.00001; 8 studies on 267 participants); however, no statistically significant effects were observed for forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), minute ventilation at maximal exercise (VEmax) or peak expiratory flow rate (PEFR). Meta-analysis of four studies detected a statistically significant increase in maximum heart rate, and following a sensitivity analysis and removal of two studies significance was maintained (MD 3.67 bpm; 95% CI 0.90 to 3.44; P = 0.01). Although there were insufficient data to pool results due to diverse reporting tools, there was some evidence to suggest that physical training may have positive effects on health-related quality of life, with four of five studies producing a statistically and clinically significant benefit. AUTHORS' CONCLUSIONS This review demonstrated that physical training showed significant improvement in maximum oxygen uptake, though no effects were observed in other measures of pulmonary function. Physical training was well tolerated among people with asthma in the included studies and, as such, people with stable asthma should be encouraged to participate in regular exercise training, without fear of symptom exacerbation. More research is needed to understand the mechanisms by which physical activity impacts asthma management.
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Hasegawa K, Chiba T, Hagiwara Y, Watase H, Tsugawa Y, Brown DF, Camargo CA. Quality of Care for Acute Asthma in Emergency Departments in Japan: A Multicenter Observational Study. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2013; 1:509-15.e1-3. [DOI: 10.1016/j.jaip.2013.05.001] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Revised: 04/28/2013] [Accepted: 05/01/2013] [Indexed: 10/26/2022]
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A randomized, comparative, multicentric clinical trial to assess the efficacy and safety of zileuton extended-release tablets with montelukast sodium tablets in patients suffering from chronic persistent asthma. Am J Ther 2013; 20:154-62. [PMID: 22926233 DOI: 10.1097/mjt.0b013e318254259b] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Leukotriene (LT) modifiers are anti-inflammatory drugs that are useful as an add-on therapy with first-line asthma-controller medications. This group includes LT synthesis inhibitors (eg, Zileuton) and receptor antagonists (eg, Montelukast), whose direct comparative clinical data are not available. This study was conducted to assess the comparative efficacy and safety of orally administered Zileuton extended-release (ER) with Montelukast sodium in patients suffering from chronic persistent asthma. Patients of 18-65 years of age with mild to moderate chronic stable asthma were randomized to treatment with Zileuton ER 2400 mg/d or Montelukast 10 mg/d for 12 weeks. Peak expiratory flow rate (PEFR) and asthma symptoms (cough, wheeze, chest tightness, and shortness of breath each on a 4-point scale) were assessed on monthly scheduled out-patient visits. Safety assessments by clinical and laboratory parameters were carried out during the course of the study. Among 210 patients eligible for efficacy assessment, PEFR improved by 64.8 ± 52.8 (95% confidence interval: 54.8-74.7) L/min with Zileuton ER (n = 109) and 40.6 ± 47.5 (31.3-49.9) L/min with Montelukast (n = 101; P < 0.001), whereas percent improvements were 27.0% (22.6%-31.5%) versus 18.4% (14.1%-22.7%), respectively (P = 0.006). Zileuton ER lead to ≥12% PEFR improvements in 74 of 109 [67.9% (59.1%-76.7%)] patients, whereas the same was noted in 52 of 101 [51.5% (41.7%-61.2%)] patients receiving Montelukast (P = 0.015). The reduction in the mean overall symptom intensity score was also significantly better with Zileuton ER [-5.0 ± 2.1 (4.6-5.4) versus -4.2 ± 2.3 (3.8-4.7)] (P = 0.018); however, the same was not observed for the decline in the individual symptom scores. A lesser but not significantly different adverse event rate was reported in the Zileuton ER group than the Montelukast group with the commonest events being headache and gastrointestinal effects in both the groups. Thus, Zileuton ER seems to be more efficacious than Montelukast and well tolerated for the treatment of mild to moderate chronic persistent asthma in adult patient population. Further studies can elucidate the comparative treatment benefits of these LT modifiers in asthma management.
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Goodacre S, Cohen J, Bradburn M, Gray A, Benger J, Coats T. Intravenous or nebulised magnesium sulphate versus standard therapy for severe acute asthma (3Mg trial): a double-blind, randomised controlled trial. THE LANCET RESPIRATORY MEDICINE 2013; 1:293-300. [PMID: 24429154 DOI: 10.1016/s2213-2600(13)70070-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Previous studies suggested intravenous or nebulised magnesium sulphate (MgSO(4)) might improve respiratory function in patients with acute asthma. We aimed to determine whether intravenous or nebulised MgSO(4) improve symptoms of breathlessness and reduce the need for hospital admission in adults with severe acute asthma. METHODS In our double-blind, placebo-controlled trial, we enrolled adults (aged ≥16 years) with severe acute asthma at emergency departments of 34 hospitals in the UK. We excluded patients with life-threatening features or contraindication to study drugs. We used a central randomisation system to allocate participants to intravenous MgSO(4) (2 g in 20 min) or nebulised MgSO(4) (three 500 mg doses in 1 h) alongside standard therapy including salbutamol, or placebo control plus standard therapy alone. We assessed two primary outcome measures in all eligible participants who started treatment, according to assigned treatment group: the proportion of patients admitted to hospital within 7 days and breathlessness measured on a 100 mm visual analogue scale (VAS) in the 2 h after initiation of treatment. We adjusted for multiple testing using Simes's method. The trial stopped before recruitment was completed because funding expired. This study is registered, number ISRCTN04417063. FINDINGS Between July 30, 2008, and June 30, 2012, we recruited 1109 (92%) of 1200 patients proposed by the power calculation. 261 (79%) of 332 patients allocated nebulised MgSO(4) were admitted to hospital before 7 days, as were 285 (72%) of 394 patients allocated intravenous MgSO(4) and 281 (78%) of 358 controls. Breathlessness was assessed in 296 (89%) patients allocated nebulised MgSO(4), 357 (91%) patients allocated intravenous MgSO(4), and 323 (90%) controls. Rates of hospital admission did not differ between patients treated with either form of MgSO(4) compared with controls or between those treated with nebulised MgSO(4) and intravenous MgSO(4). Change in VAS breathlessness did not differ between active treatments and control, but change in VAS was greater for patients in the intravenous MgSO(4) group than it was in the nebulised MgSO(4) group (5·1 mm, 0·8 to 9·4; p=0·019). Intravenous or nebulised MgSO(4) did not significantly decrease rates of hospital admission and breathlessness compared with placebo: intravenous MgSO(4) was associated with an odds ratio of 0·73 (95% CI 0·51 to 1·04; p=0·083) for hospital admission and a change in VAS breathlessness of 2·6 mm (-1·6 to 6·8; p=0·231) compared with placebo; nebulised MgSO(4) was associated with an odds ratio of 0·96 (0·65 to 1·40; p=0·819) for hospital admission and a change in VAS breathlessness of -2·6 mm (-7·0 to 1·8; p=0·253) compared with placebo. INTERPRETATION Our findings suggest nebulised MgSO(4) has no role in the management of severe acute asthma in adults and at best suggest only a limited role for intravenous MgSO(4) in this setting. FUNDING UK National Institute for Health Research Health Technology Assessment Programme.
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Affiliation(s)
- Steve Goodacre
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK.
| | - Judith Cohen
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Mike Bradburn
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Alasdair Gray
- Emergency Department, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Jonathan Benger
- Faculty of Health and Life Sciences, University of the West of England, Bristol, UK
| | - Timothy Coats
- Emergency Department, Leicester Royal Infirmary, Leicester, UK
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Edmonds ML, Milan SJ, Camargo CA, Pollack CV, Rowe BH. Early use of inhaled corticosteroids in the emergency department treatment of acute asthma. Cochrane Database Syst Rev 2012; 12:CD002308. [PMID: 23235589 PMCID: PMC6513646 DOI: 10.1002/14651858.cd002308.pub2] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Systemic corticosteroid therapy is central to the management of acute asthma. The use of inhaled corticosteroids (ICS) may also be beneficial in this setting. OBJECTIVES To determine the benefit of ICS for the treatment of patients with acute asthma managed in the emergency department (ED). SEARCH METHODS We identified controlled clinical trials from the Cochrane Airways Group specialised register of controlled trials. Bibliographies from included studies, known reviews, and texts also were searched. The latest search was September 2012. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs. Studies were included if patients presented to the ED or its equivalent with acute asthma, and were treated with ICS or placebo, in addition to standard therapy. Two review authors independently selected potentially relevant articles, and then independently selected articles for inclusion. Methodological quality was independently assessed by two review authors. There were three different types of studies that were included in this review: 1) studies comparing ICS vs. placebo, with no systemic corticosteroids given to either treatment group, 2) studies comparing ICS vs. placebo, with systemic corticosteroids given to both treatment groups, and 3) studies comparing ICS alone versus systemic corticosteroids. For the analysis, the first two types of studies were included as separate subgroups in the primary analysis (ICS vs. placebo), while the third type of study was included in the secondary analysis (ICS vs. systemic corticosteroid). DATA COLLECTION AND ANALYSIS Data were extracted independently by two review authors if the authors were unable to verify the validity of extracted information. Missing data were obtained from the authors or calculated from other data presented in the paper. Where appropriate, individual and pooled dichotomous outcomes were reported as odds ratios (OR) with 95% confidence intervals (CIs). Where appropriate, individual and pooled continuous outcomes were reported as mean differences (MD) or standardized mean differences (SMD) with 95% CIs. The primary analysis employed a fixed-effect model and a random-effects model was used for sensitivity analysis. Heterogeneity is reported using I-squared (I(2)) statistics. MAIN RESULTS Twenty trials were selected for inclusion in the primary analysis (13 paediatric, seven adult), with a total number of 1403 patients. Patients treated with ICS were less likely to be admitted to hospital (OR 0.44; 95% CI 0.31 to 0.62; 12 studies; 960 patients) and heterogeneity (I(2) = 27%) was modest. This represents a reduction from 32 to 17 hospital admissions per 100 patients treated with ICS in comparison with placebo. Subgroup analysis of hospital admissions based on concomitant systemic corticosteroid use revealed that both subgroups indicated benefit from ICS in reducing hospital admissions (ICS and systemic corticosteroid versus systemic corticosteroid: OR 0.54; 95% CI 0.36 to 0.81; 5 studies; N = 433; ICS versus placebo: OR 0.27; 95% CI 0.14 to 0.52; 7 studies; N = 527). However, there was moderate heterogeneity in the subgroup using ICS in addition to systemic steroids (I(2) = 52%). Patients receiving ICS demonstrated small, significant improvements in peak expiratory flow (PEF: MD 7%; 95% CI 3% to 11%) and forced expiratory volume in one second (FEV(1): MD 6%; 95% CI 2% to 10%) at three to four hours post treatment). Only a small number of studies reported these outcomes such that they could be included in the meta-analysis and most of the studies in this comparison did not administer systemic corticosteroids to either treatment group. There was no evidence of significant adverse effects from ICS treatment with regard to tremor or nausea and vomiting. In the secondary analysis of studies comparing ICS alone versus systemic corticosteroid alone, heterogeneity among the studies complicated pooling of data or drawing reliable conclusions. AUTHORS' CONCLUSIONS ICS therapy reduces hospital admissions in patients with acute asthma who are not treated with oral or intravenous corticosteroids. They may also reduce admissions when they are used in addition to systemic corticosteroids; however, the most recent evidence is conflicting. There is insufficient evidence that ICS therapy results in clinically important changes in pulmonary function or clinical scores when used in acute asthma in addition to systemic corticosteroids. Also, there is insufficient evidence that ICS therapy can be used in place of systemic corticosteroid therapy when treating acute asthma. Further research is needed to clarify the most appropriate drug dosage and delivery device, and to define which patients are most likely to benefit from ICS therapy. Use of similar measures and reporting methods of lung function, and a common, validated, clinical score would be helpful in future versions of this meta-analysis.
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Oxberry SG, Bland JM, Clark AL, Cleland JG, Johnson MJ. Minimally clinically important difference in chronic breathlessness: every little helps. Am Heart J 2012; 164:229-35. [PMID: 22877809 DOI: 10.1016/j.ahj.2012.05.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2012] [Accepted: 05/11/2012] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aim of the study was to determine the minimally clinically important difference (MCID) for breathlessness due to chronic heart failure (CHF). BACKGROUND The measurement of breathlessness is difficult because it is subjective and multifactorial. Statistically significant changes in assessment may not be clinically meaningful. This is the first determination of MCID in chronic breathlessness in CHF using patient-rated data. METHODS Measurements were made as part of a randomized, controlled, crossover trial of morphine, oxycodone, or placebo for breathlessness in CHF. Breathlessness intensity was assessed at baseline and at the end of each intervention (day 4) using 11-point numerical rating scales (NRS), modified Borg (mBorg) scales, and global impression of change (GC) in breathlessness at day 4. From these data, the change in NRS or mBorg associated with a 1-point change in GC was calculated. RESULTS Thirty-five patients completed all study interventions, resulting in 105 data sets. We defined MCID as a 1-point change in GC. Regression analysis found that the MCID, including 95% CIs, equaled change in average NRS breathlessness per 24 hours of 0.5 to 2.0 U (P < .001), change in worst NRS breathlessness per 24 hours of 0.4 to 2.9 (P < .001), change in average mBorg score of 0.2 to 2.0 (P < .001), and change in worst mBorg score as between 0.3 and 1.9 (P < .001). Corresponding effect size calculations lay within the 95% CIs for the regression analysis for each measure. CONCLUSIONS A 1-point change in NRS or mBorg score is a reasonable estimate of the MCID in average daily chronic breathlessness in CHF.
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Abstract
BACKGROUND People with asthma may show less tolerance to exercise due to worsening asthma symptoms during exercise or other reasons such as deconditioning, as a consequence of inactivity. Some may also restrict activities as per medical advice or family influence and this might result in reduced physical fitness. Physical training programs aim to improve physical fitness, neuromuscular coordination and self confidence. Subjectively, many people with asthma report that they are symptomatically better when fit, but results from trials have varied and have been difficult to compare because of different designs and training protocols. Also, as exercise can induce asthma, the safety of exercise programmes need to be considered. OBJECTIVES To gain a better understanding of the effect of physical training on the respiratory and general health of people with asthma, from randomised trials. SEARCH METHODS We searched the Cochrane Airways Group Specialised Register of trials up to April 2011. SELECTION CRITERIA We included randomised trials of people over eight years of age with asthma who were randomised to undertake physical training. Physical training had to be undertaken for at least twenty minutes, two times a week, over a minimum period of four weeks. DATA COLLECTION AND ANALYSIS Two review authors independently assessed eligibility for inclusion and the quality of trials. MAIN RESULTS Nineteen studies (695 participants) were included in this review. Physical training was well tolerated with no adverse effects reported. None of the studies mentioned worsening of asthma symptoms following physical training. Physical training improved cardiopulmonary fitness as measured by a statistically and clinically significant increase in maximum oxygen uptake (MD 5.57 mL/kg/min; 95% confidence interval (CI) 4.36 to 6.78; six studies on 149 participants) and maximum expiratory ventilation (6.0 L/min, 95% CI 1.57 to 10.43; four studies on 111 participants) with no significant effect on resting lung function (performed in four studies). Although there were insufficient data to pool due to diverse reporting tools, there is some evidence available to suggest that physical training may have positive effects on health-related quality of life, with four of five studies producing a statistically and clinically significant benefit. AUTHORS' CONCLUSIONS This review demonstrated that physical training can improve cardiopulmonary fitness and was well tolerated among people with asthma in the included studies. As such, people with stable asthma should be encouraged to partake in regular exercise training, without fear of symptom exacerbation.
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Chew KS, Kamarudin H, Hashim CW. A randomized open-label trial on the use of budesonide/formoterol (Symbicort®) as an alternative reliever medication for mild to moderate asthmatic attacks. Int J Emerg Med 2012; 5:16. [PMID: 22503137 PMCID: PMC3352303 DOI: 10.1186/1865-1380-5-16] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Accepted: 04/13/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Conventionally, a nebulized short-acting β-2 agonist like salbutamol is often used as the reliever in acute exacerbations of asthma. However, recent worldwide respiratory outbreaks discourage routine use of nebulization. Previous studies have shown that combined budesonide/formoterol (Symbicort®, AstraZeneca) is effective as both a maintenance and reliever anti-asthmatic medication. METHODS We performed a randomized, open-label study from March until August 2011 to compare the bronchodilatory effects of Symbicort® vs. nebulized salbutamol in acute exacerbation of mild to moderate asthmatic attack in an emergency department. Initial objective parameters measured include the oxygen saturation, peak expiratory flow rate (PEFR) and respiratory rate. During clinical reassessment, subjective parameters [i.e., Visual Analog Scale (VAS) and 5-point Likert scale of breathlessness] and the second reading of the objective parameters were measured. For the 5-point Likert scale, the patients were asked to describe their symptom relief as 1, much worse; 2, a little worse; 3, no change; 4, a little better; 5, much better. RESULTS Out of the total of 32 patients enrolled, 17 patients (53%) were randomized to receive nebulized salbutamol and 15 (47%) to receive Symbicort®. For both treatment arms, by using paired t- and Wilcoxon signed rank tests, it was shown that there were statistically significant improvements in oxygen saturation, PEFR and respiratory rate within the individual treatment groups (pre- vs. post-treatment). Comparing the effects of Symbicort® vs. nebulized salbutamol, the average improvement of oxygen saturation was 1% in both treatment arms (p = 0.464), PEFR 78.67 l/min vs. 89.41 l/min, respectively (p = 0.507), and respiratory rate 2/min vs. 2/min (p = 0.890). For subjective evaluation, all patients reported improvement in the VAS (average 2.45 cm vs. 2.20 cm), respectively (p = 0.765). All patients in both treatment arms reported either "a little better" or "much better" on the 5-point Likert scale, with none reporting "no change" or getting worse. CONCLUSION This study suggests that there is no statistical difference between using Symbicort® vs. nebulized salbutamol as the reliever for the first 15 min post-intervention.
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Affiliation(s)
- Keng Sheng Chew
- Emergency Medicine Department, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, 16150 Kota Bharu, Kelantan, Malaysia
| | - Hamizah Kamarudin
- Emergency Medicine Department, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, 16150 Kota Bharu, Kelantan, Malaysia
| | - Che Wan Hashim
- Respiratory and Medical Clinic, Kota Bharu Medical Centre, 16150 Kota Bharu, Malaysia
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Ezekowitz JA, Hernandez AF, O'Connor CM, Starling RC, Proulx G, Weiss MH, Bakal JA, Califf RM, McMurray JJ, Armstrong PW. Assessment of Dyspnea in Acute Decompensated Heart Failure. J Am Coll Cardiol 2012; 59:1441-8. [DOI: 10.1016/j.jacc.2011.11.061] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Revised: 11/26/2011] [Accepted: 11/29/2011] [Indexed: 01/08/2023]
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Johnson MJ, Abernethy AP, Currow DC. Gaps in the evidence base of opioids for refractory breathlessness. A future work plan? J Pain Symptom Manage 2012; 43:614-24. [PMID: 22285285 DOI: 10.1016/j.jpainsymman.2011.04.024] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Revised: 04/25/2011] [Accepted: 04/27/2011] [Indexed: 11/17/2022]
Abstract
Breathlessness or "shortness of breath," medically termed dyspnea, remains a devastating problem for many people and those who care for them. As a treatment intervention, administration of opioids to relieve breathlessness is an area where progress has been made with the development of an evidence base. As evidence in support of opioids has accumulated, so has our collective understanding about trial methodology, research collaboration, and infrastructure that is crucial to generate reliable research results for palliative care clinical settings. Analysis of achievements to date and what it takes to accomplish these studies provides important insights into knowledge gaps needing further research and practical insight into design of pharmacological and nonpharmacological intervention trials in breathlessness and palliative care. This article presents the current understanding of opioids for treating breathlessness, what is still unknown as priorities for future research, and highlights methodological issues for consideration in planned studies.
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SMITH TRACYA, DAVIDSON PATRICIAM, LAM LAWRENCET, JENKINS CHRISTINER, INGHAM JANEM. The use of non-invasive ventilation for the relief of dyspnoea in exacerbations of chronic obstructive pulmonary disease; a systematic review. Respirology 2012; 17:300-7. [DOI: 10.1111/j.1440-1843.2011.02085.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
Asthma is a chronic inflammatory airway disease that is commonly seen in the emergency department (ED). This article provides an evidence-based review of diagnosis and management of asthma. Early recognition of asthma exacerbations and initiation of treatment are essential. Treatment is dictated by the severity of the exacerbation. Treatment involves bronchodilators and corticosteroids. Other treatment modalities including magnesium, heliox, and noninvasive ventilator support are discussed. Safe disposition from the ED can be considered after stabilization of the exacerbation, response to treatment and attaining peak flow measures.
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Currow DC, McDonald C, Oaten S, Kenny B, Allcroft P, Frith P, Briffa M, Johnson MJ, Abernethy AP. Once-daily opioids for chronic dyspnea: a dose increment and pharmacovigilance study. J Pain Symptom Manage 2011; 42:388-99. [PMID: 21458217 DOI: 10.1016/j.jpainsymman.2010.11.021] [Citation(s) in RCA: 192] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2010] [Revised: 11/24/2010] [Accepted: 12/03/2010] [Indexed: 10/18/2022]
Abstract
CONTEXT Randomized controlled trials can answer questions of efficacy, but long-term pharmacovigilance studies generate complementary safety data. OBJECTIVES Level I evidence supports short-term efficacy of opioids in reducing chronic refractory dyspnea. This study aimed to determine the minimum effective once-daily dose of sustained-release morphine, and whether net clinical benefits are sustained safely. METHODS In a Phase II dose increment study, 10mg daily of sustained-release morphine was administered, and increased in nonresponders by 10mg daily each week to a maximum of 30 mg daily. The participant was withdrawn if there were unacceptable side effects or no response to maximum dose. If participants had a 10% improvement in dyspnea over their own baseline, they joined a long-term Phase IV effectiveness/safety study at that dose. Complying with Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines, response and side effects are described, with demographic and clinical characteristics of responders. RESULTS Eighty-three participants (53 males, mean age 75 years, 54% with chronic obstructive pulmonary disease) provided more than 30 patient-years of data. Fifty-two participants derived ≥ 10% benefit (on average 35% improvement over baseline), giving a response rate of 62% (number needed to treat of 1.6: number needed to harm 4.6); for 70%, this dose was 10mg/24h. Benefit was maintained at three months for 28 (33%) people. Ranking of breathlessness was reduced significantly (P<0.001), but constipation increased (P<0.001) despite laxatives. There were no episodes of respiratory depression or hospitalizations as a result of the sustained-release morphine. Overall, one in three people continued to derive benefit at three months. CONCLUSION Ten milligrams of sustained-release oral morphine once daily is safe and effective for most people who respond.
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Affiliation(s)
- David C Currow
- Discipline, Palliative and Supportive Services, Flinders University, Bedford Park, SA, Australia.
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Affiliation(s)
- Stephen C Lazarus
- Division of Pulmonary and Critical Care Medicine and the Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA 94143-0111, USA.
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West RL, Hernandez AF, O'Connor CM, Starling RC, Califf RM. A review of dyspnea in acute heart failure syndromes. Am Heart J 2010; 160:209-14. [PMID: 20691823 DOI: 10.1016/j.ahj.2010.05.020] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2010] [Accepted: 05/15/2010] [Indexed: 10/19/2022]
Abstract
In acute heart failure syndrome (AHFS), dyspnea is one of the most common but least understood presenting symptoms for hospitalization. For this reason, dyspnea relief is increasingly becoming a focus in the development of therapies for the treatment of AHFS, and currently stands as an acceptable primary end point for regulatory approval by governmental agencies. This raises the question of how best to measure such a subjective symptom. In this review, we will describe the basis for dyspnea, provide a detailed description of the strengths and weaknesses of the current best tools used to measure it, and describe future directions for future development of dyspnea measurement in AHFS.
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Johnson MJ, Oxberry SG, Cleland JG, Clark AL. Measurement of breathlessness in clinical trials in patients with chronic heart failure: the need for a standardized approach: a systematic review. Eur J Heart Fail 2010; 12:137-47. [DOI: 10.1093/eurjhf/hfp194] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Miriam J. Johnson
- Hull York Medical School and St Catherine's Hospice; Scarborough North Yorkshire YO12 5RE UK
- Department of Academic Cardiology; Hull York Medical School, Castle Hill Hospital; Hull East Yorkshire UK
| | - Stephen G. Oxberry
- Department of Academic Cardiology; Hull York Medical School, Castle Hill Hospital; Hull East Yorkshire UK
| | - John G.F. Cleland
- Department of Academic Cardiology; Hull York Medical School, Castle Hill Hospital; Hull East Yorkshire UK
| | - Andrew L. Clark
- Department of Academic Cardiology; Hull York Medical School, Castle Hill Hospital; Hull East Yorkshire UK
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Meek R, Kelly AM, Hu XF. Use of the visual analog scale to rate and monitor severity of nausea in the emergency department. Acad Emerg Med 2009; 16:1304-1310. [PMID: 20053251 DOI: 10.1111/j.1553-2712.2009.00581.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The objective was to describe the association between verbal descriptors of nausea severity and visual analog scale (VAS) ratings in an undifferentiated emergency department (ED) population and to calculate the minimum clinically significant difference (MCSD) in VAS rating of nausea severity in this population. METHODS A prospective observational study was conducted at three EDs on a convenience sample of stable, consenting adult patients presenting with nausea as part of their symptom complex. Data included demographics, adjectival description of nausea severity (none, mild, moderate, or severe), and VAS rating (standard 100-mm line) at enrollment, 30 minutes, and 60 minutes. At 30 and 60 minutes they were also asked to describe any change in nausea severity from the previous rating ("a lot less,""a little less,""the same,""a little more,""a lot more"). The MCSD was defined as the average VAS change when a patient reported "a little less" or "a little more" nausea. RESULTS A total of 247 patients provided 693 matched adjectival ratings and VAS scores. Median age was 45 years, and 100 (40%) were male. The median VAS measures for none, mild, moderate, and severe nausea were 2, 23, 53, and 83 mm, respectively. VAS distributions in the verbal categories were statistically different from each other (Spearman rank correlation coefficient = 0.90; p < 0.0001). The MCSD was 22 mm (95% CI = 20 to 24 mm). CONCLUSIONS There is very good correlation between verbal descriptors of nausea and VAS ratings. The MCSD for VAS nausea ratings in an ED population is 22 mm.
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Affiliation(s)
- Robert Meek
- From the Emergency Department, Dandenong Hospital (RM, XFH), Dandenong, Victoria; and the Joseph Epstein Centre for Emergency Medicine Research at Western Health, Footscray (AMK), Victoria, Australia
| | - Anne-Maree Kelly
- From the Emergency Department, Dandenong Hospital (RM, XFH), Dandenong, Victoria; and the Joseph Epstein Centre for Emergency Medicine Research at Western Health, Footscray (AMK), Victoria, Australia
| | - Xue Feng Hu
- From the Emergency Department, Dandenong Hospital (RM, XFH), Dandenong, Victoria; and the Joseph Epstein Centre for Emergency Medicine Research at Western Health, Footscray (AMK), Victoria, Australia
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Camargo CA, Rachelefsky G, Schatz M. Managing asthma exacerbations in the emergency department: summary of the National Asthma Education and Prevention Program Expert Panel Report 3 guidelines for the management of asthma exacerbations. J Emerg Med 2009; 37:S6-S17. [PMID: 19683665 DOI: 10.1016/j.jemermed.2009.06.105] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Carlos A Camargo
- Department of Emergency Medicine and Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Khan FI, Reddy RC, Baptist AP. Pediatric Dyspnea Scale for use in hospitalized patients with asthma. J Allergy Clin Immunol 2009; 123:660-4. [PMID: 19181371 DOI: 10.1016/j.jaci.2008.12.018] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2008] [Revised: 11/04/2008] [Accepted: 12/16/2008] [Indexed: 11/24/2022]
Abstract
BACKGROUND Asthma is a leading cause of pediatric hospitalizations across the country, yet no clinical instrument exists that incorporates the child's perception of dyspnea in determining discharge readiness. OBJECTIVE We sought to develop the Pediatric Dyspnea Scale (PDS) to support discharge decision making in hospitalized asthmatic patients and to compare the performance of the PDS with traditional markers of asthma control in predicting outcomes after discharge. METHODS Asthmatic children aged 6 to 18 years hospitalized for an exacerbation were included in the study. The PDS score, demographics, asthma severity, spirometric results, peak expiratory flow rate, and fraction of exhaled nitric oxide were assessed at the time of discharge. A telephone call 14 days after discharge determined relapse, activity limitation, asthma control, and asthma-related quality-of-life outcomes. RESULTS Eighty-nine patients were enrolled, of whom 70 completed the telephone follow-up. Eight patients had a relapse, and 29 complained of limited activity. A PDS score of greater than 2 on the 7-point scale was a significant predictor of these poor outcomes, with each additional point of the PDS doubling the risk. A higher score on the PDS also correlated with worse asthma control and poor asthma-specific quality of life. The PDS performed better than FEV(1), peak expiratory flow rate, or fraction of exhaled nitric oxide in predicting the outcomes of interest. CONCLUSION The PDS, which is easy to use in children as young as 6 years of age, might be able to predict adverse outcomes after hospitalization for an asthma exacerbation and should be used as a tool to help guide inpatient discharge decisions.
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Affiliation(s)
- Farah I Khan
- Carman and Ann Adams Department of Pediatrics, Division of Allergy, Immunology and Rheumatology, Children's Hospital of Michigan, Wayne State University, Detroit, Mich, USA
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Baptist AP, Khan FI, Wang Y, Ager J. Exhaled nitric oxide measurements in hospitalized children with asthma. J Asthma 2008; 45:670-4. [PMID: 18951258 DOI: 10.1080/02770900802140207] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND The reproducibility of exhaled nitric oxide (FE(NO)) measurements performed in pediatric hospitalized asthmatics has not been previously evaluated. OBJECTIVE To evaluate the reproducibility of FE(NO) measurements in the hospital; to look for differences between those who were and were not able to perform FE(NO) measurements; and to assess any factors correlated with FE(NO) measurements. METHODS 89 hospitalized pediatric asthmatics performed FE(NO), FEV1, and peak expiratory flow rate (PEFR) maneuvers in triplicate at the time of discharge. Reproducibility was assessed using the intraclass correlation coefficient (ICC) and coefficient of variation (CV). Demographic and measured variables were compared between those who were and were not able to perform FE(NO) measurements. Correlation of FE(NO) with other variables was investigated. RESULTS FE(NO) measurements showed clinically acceptable ICC and CV values (0.973 and 5.59%, respectively). These values were superior to the values obtained for FEV1 and PEFR. Subjects who successfully performed the FE(NO) measurements were older, had higher PEFR readings, and had a lower asthma dyspnea score. No correlation was found between FE(NO) and traditional asthma factors, though multiple factors did trend towards significance. CONCLUSION FE(NO) measurements can be obtained in hospitalized pediatric patients with good reproducibility. While the majority of children will be able to provide such readings, those who are younger and with a more severe exacerbation may be unsuccessful in doing so. Further research is needed to determine how best to incorporate FE(NO) values into the hospital setting.
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Affiliation(s)
- Alan P Baptist
- Division of Allergy and Clinical Immunology, University of Michigan School of Medicine, Ann Arbor, MI, USA.
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Gray A, Goodacre S, Newby DE, Masson M, Sampson F, Nicholl J. Noninvasive ventilation in acute cardiogenic pulmonary edema. N Engl J Med 2008; 359:142-51. [PMID: 18614781 DOI: 10.1056/nejmoa0707992] [Citation(s) in RCA: 350] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Noninvasive ventilation (continuous positive airway pressure [CPAP] or noninvasive intermittent positive-pressure ventilation [NIPPV]) appears to be of benefit in the immediate treatment of patients with acute cardiogenic pulmonary edema and may reduce mortality. We conducted a study to determine whether noninvasive ventilation reduces mortality and whether there are important differences in outcome associated with the method of treatment (CPAP or NIPPV). METHODS In a multicenter, open, prospective, randomized, controlled trial, patients were assigned to standard oxygen therapy, CPAP (5 to 15 cm of water), or NIPPV (inspiratory pressure, 8 to 20 cm of water; expiratory pressure, 4 to 10 cm of water). The primary end point for the comparison between noninvasive ventilation and standard oxygen therapy was death within 7 days after the initiation of treatment, and the primary end point for the comparison between NIPPV and CPAP was death or intubation within 7 days. RESULTS A total of 1069 patients (mean [+/-SD] age, 77.7+/-9.7 years; female sex, 56.9%) were assigned to standard oxygen therapy (367 patients), CPAP (346 patients), or NIPPV (356 patients). There was no significant difference in 7-day mortality between patients receiving standard oxygen therapy (9.8%) and those undergoing noninvasive ventilation (9.5%, P=0.87). There was no significant difference in the combined end point of death or intubation within 7 days between the two groups of patients undergoing noninvasive ventilation (11.7% for CPAP and 11.1% for NIPPV, P=0.81). As compared with standard oxygen therapy, noninvasive ventilation was associated with greater mean improvements at 1 hour after the beginning of treatment in patient-reported dyspnea (treatment difference, 0.7 on a visual-analogue scale ranging from 1 to 10; 95% confidence interval [CI], 0.2 to 1.3; P=0.008), heart rate (treatment difference, 4 beats per minute; 95% CI, 1 to 6; P=0.004), acidosis (treatment difference, pH 0.03; 95% CI, 0.02 to 0.04; P<0.001), and hypercapnia (treatment difference, 0.7 kPa [5.2 mm Hg]; 95% CI, 0.4 to 0.9; P<0.001). There were no treatment-related adverse events. CONCLUSIONS In patients with acute cardiogenic pulmonary edema, noninvasive ventilation induces a more rapid improvement in respiratory distress and metabolic disturbance than does standard oxygen therapy but has no effect on short-term mortality. (Current Controlled Trials number, ISRCTN07448447.)
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Affiliation(s)
- Alasdair Gray
- Royal Infirmary of Edinburgh, Edinburgh, United Kingdom.
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Baptist AP, Sengupta R, Pranathiageswaran S, Wang Y, Ager J. Evaluation of exhaled nitric oxide measurements in the emergency department for patients with acute asthma. Ann Allergy Asthma Immunol 2008; 100:415-9. [PMID: 18517071 DOI: 10.1016/s1081-1206(10)60464-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Fraction of exhaled nitric oxide (FE(NO)) measurements performed on patients with acute asthma in the emergency department (ED) have previously shown poor reproducibility. OBJECTIVES To evaluate the reproducibility of FE(NO) measurements in the ED using a new monitoring device, to evaluate any factors that may correlate with FE(NO) measurements, and to investigate if FE(NO) levels predict the need for admission to the hospital. METHODS Thirty-five adult patients with asthma seen in the ED performed FE(NO), forced expiratory volume in 1 second, and peak expiratory flow rate maneuvers in triplicate. Reproducibility was evaluated using the intraclass correlation coefficient and the coefficient of variation. Associations between FE(NO), demographic, and traditional asthma measurements were investigated. The FE(NO) levels between patients admitted for further care and those discharged home were compared. RESULTS The FE(NO) measurements showed acceptable intraclass correlation coefficient and coefficient of variation values (0.98 and 9.42%, respectively) for reproducibility. These values were superior to the values obtained for forced expiratory volume in 1 second and peak expiratory flow rate. No correlation was found between FE(NO) and traditional asthma factors, although length of the asthma attack trended toward statistical significance (P = .08). The FE(NO) levels did not differ between those admitted and those discharged home (P = .53). CONCLUSIONS Fraction of exhaled nitric oxide measurements can be obtained in the ED setting with good reproducibility. These measurements may provide useful information not obtainable by other means. Further research is needed to determine how best to incorporate FE(NO) values into the ED setting.
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Affiliation(s)
- Alan P Baptist
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA.
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Bausewein C, Farquhar M, Booth S, Gysels M, Higginson IJ. Measurement of breathlessness in advanced disease: A systematic review. Respir Med 2007; 101:399-410. [PMID: 16914301 DOI: 10.1016/j.rmed.2006.07.003] [Citation(s) in RCA: 152] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2006] [Revised: 06/30/2006] [Accepted: 07/04/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND There is a plethora of assessment tools available to measure breathlessness, the most common and disabling symptom of advanced cardio-respiratory disease. The aim of this systematic review was to identify all measures available via standard search techniques and review their usefulness for patients with advanced disease. METHODS A systematic literature search was performed in Medline. All studies focusing on the development or evaluation of tools for measuring breathlessness in chronic respiratory disease, cardiac disease, cancer, or MND were identified. Their characteristics with regard to validity, reliability, appropriateness and responsiveness to change were described. The tools were then examined for their usefulness in measuring significant aspects of breathlessness in advanced disease. RESULTS Thirty-five tools were initially identified, two were excluded. Twenty-nine were multidimensional of which 11 were breathlessness-specific and 18 disease-specific. Four tools were unidimensional, measuring the severity of breathlessness. The majority of disease-specific scales were validated for chronic obstructive pulmonary disease (COPD), few were applicable in other conditions. No one tool assessed all the dimensions of this complex symptom, which affects the psychology and social functioning of the affected individual and their family--most focused on physical activity. CONCLUSION As yet there is no one scale that can accurately reflect the far-reaching effects of breathlessness on the patient with advanced disease and their family. Therefore, at present, we would recommend combining a unidimensional scale (e.g. VAS) with a disease-specific scale (where available) or a multidimensional scale in conjunction with other methods (such as qualitative techniques) to gauge psychosocial and carer distress for the assessment of breathlessness in advanced disease.
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Affiliation(s)
- C Bausewein
- Department of Palliative Care, Policy and Rehabilitation, King's College London, Weston Education Centre, Denmark Hill, Cutcombe Road, London SE5 9RJ, UK.
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Harrison MJ. Variation in preoperative assessment of cardiac output reserve and likelihood of transfusion among anaesthetists: a pilot study. Anaesth Intensive Care 2006; 34:453-6. [PMID: 16913341 DOI: 10.1177/0310057x0603400407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The aim of this pilot study was to investigate anaesthetists' assessment of the ability of patients to increase cardiac output over a range of clinical scenarios and of their perceived 'likelihood of transfusion' in these scenarios. Specialist anaesthetists were given a questionnaire with clinical cues in the form of diagnoses about theoretical patients. They were asked to use 100 mm visual analogue scales (VAS) for their assessments of each patient's cardiac reserve and their 'likelihood of transfusion' of these patients; the endpoints of the VAS being 'Very low' (0 mm) to 'High' (100 mm), and 'Do not transfuse' (0 mm) to 'Transfuse' (100 mm) respectively. The assessment of patients' cardiac output reserve by anaesthetists (n = 54) showed great variation; for example, a patient with severe aortic stenosis was perceived overall to have a limited ability to increase cardiac output (mean VAS 16 mm) but there was considerable variation between anaesthetists (25-75 percentiles 10 mm to 21 mm). Assessment of 'likelihood of transfusion' (n = 42) also had great variation; as an example a patient with 'angina' with a haemoglobin of 95 g l(-1) was perceived overall to have an average likelihood of transfusion of 50 mm, but the 25-75 percentiles ranged from 33 mm to 71 mm. This study suggests that inter-anaesthetist variability in the assessment of a patient's 'cardiac output reserve' and his 'likelihood of transfusion' is large.
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Affiliation(s)
- M J Harrison
- Department of Anaesthesia, Auckland City Hospital, Auckland, New Zealand
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Lasheen W, Panneerselvam A, Davis MP. Can we really say that nebulized morphine works? J Pain Symptom Manage 2006; 32:101-2; author reply 102-3. [PMID: 16877173 DOI: 10.1016/j.jpainsymman.2006.03.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2006] [Accepted: 03/27/2006] [Indexed: 11/19/2022]
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Poole PJ, Saini R, Brodie SM, Black PN. Comparison of the effects of nebulised and inhaled salbutamol on breathlessness in severe COPD. Respir Med 2005; 99:372-6. [PMID: 15733514 DOI: 10.1016/j.rmed.2004.08.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2003] [Accepted: 08/03/2004] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patients with chronic obstructive pulmonary disease (COPD) often report greater relief of breathlessness with nebulised bronchodilators than with the same medicine administered from a metered dose inhaler (MDI). This suggests that the nebulised medicines may have an effect on breathlessness over and above changes in lung function resulting from bronchodilatation. METHODS Twenty-four subjects with COPD and breathlessness at rest participated in this randomised, crossover trial. The mean age was 72 years and the mean FEV(1) was 26% of predicted. Subjects were studied on four separate days. On two days they were treated with nebulised salbutamol and on the other 2 days with salbutamol from an MDI and spacer. With each method of delivery, local anaesthetic cream was applied to the face on one day and to the back of the hand on the other. RESULTS Five minutes after administration of salbutamol the subjects were significantly less breathless with nebulised salbutamol but by 45 min both treatments resulted in equivalent relief. There was no difference between the treatments in the change in FEV(1) or VC and application of local anaesthetic to the face did not influence the response. CONCLUSION There was a small early benefit with nebulised salbutamol but this was not sustained and was not affected by topical anaesthesia. The benefit of nebulisation does not appear to be large enough to warrant the routine, widespread use of nebulised bronchodilators for the treatment of stable COPD.
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Affiliation(s)
- P J Poole
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland, New Zealand.
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Hendey GW, Donner NF, Fuller K. Clinically significant changes in nausea as measured on a visual analog scale. Ann Emerg Med 2005; 45:77-81. [PMID: 15635314 DOI: 10.1016/j.annemergmed.2004.07.446] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
STUDY OBJECTIVE Our objective is to determine the minimum clinically significant change in nausea as measured on a visual analog scale. METHODS This was a prospective, descriptive, convenience sample study of consenting adults presenting to the emergency department with nausea, excluding intoxicated patients and those with mild nausea (measuring <30 mm on a visual analog scale). Patients rated their nausea severity on a 100-mm visual analog scale and reported whether their nausea was "a lot less," "a little less," "unchanged," "a little more," or "a lot more" compared with previous assessments. We defined the minimum clinically significant change as the mean difference in visual analog scale in patients reporting "a little less" or "a little more" nausea. RESULTS Eighty-three paired visual analog scale measurements were collected from 50 patients. Fifty-eight percent of patients were women, and the mean age was 41 years. Mean changes in visual analog scale with corresponding qualitative descriptors were "a lot less" in 16 paired measurements (-42.2 mm; 95% confidence interval [CI] -54.9 to -29.5); "a little less" in 34 paired measurements (-15.4 mm; 95% CI -20.0 to -10.8); "no change" in 28 paired measurements (-0.4 mm; 95% CI -5.6 to 4.8); "a little more" in 2 paired measurements (16 mm; 95% CI -86 to 118); and "a lot more" in 3 paired measurements (23.7 mm; 95% CI -5.4 to 52.8). Patients reported "a little more" or "a little less" nausea in 36 paired measurements, with a mean change in visual analog scale of 15.4 mm (95% CI 11.0 to 19.8). CONCLUSION The minimum clinically significant visual analog scale change in nausea was 15 mm, which is similar to previous studies of other symptoms, and helps in the interpretation of clinical studies reporting changes in nausea.
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Affiliation(s)
- Gregory W Hendey
- University of California, San Francisco-Fresno, University Medical Center, Fresno, CA 93702, USA.
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Coppieters MW, Bartholomeeusen KE, Stappaerts KH. Incorporating Nerve-Gliding Techniques in the Conservative Treatment of Cubital Tunnel Syndrome. J Manipulative Physiol Ther 2004; 27:560-8. [PMID: 15614243 DOI: 10.1016/j.jmpt.2004.10.006] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To discuss the diagnosis and treatment of a patient with cubital tunnel syndrome and to illustrate novel treatment modalities for the ulnar nerve and its surrounding structures and target tissues. The rationale for the addition of nerve-gliding techniques will be highlighted. CLINICAL FEATURES Two months after onset, a 17-year-old female nursing student who had a traumatic onset of cubital tunnel syndrome still experienced pain around the elbow and paresthesia in the ulnar nerve distribution. Electrodiagnostic tests were negative. Segmental cervicothoracic motion dysfunctions were present which were regarded as contributing factors hindering natural recovery. INTERVENTION AND OUTCOMES After 6 sessions consisting of nerve-gliding techniques and segmental joint manipulation and a home exercise program consisting of nerve gliding and light free-weight exercises, a substantial improvement was recorded on both the impairment and functional level (pain scales, clinical tests, and Northwick Park Questionnaire). Symptoms did not recur within a 10-month follow-up period, and pain and disability had completely resolved. CONCLUSIONS Movement-based management may be beneficial in the conservative management of cubital tunnel syndrome. As this intervention is in contrast with the traditional recommendation of immobilization, comparing the effects of both interventions in a systematic way is an essential next step to determine the optimal treatment of patients with cubital tunnel syndrome.
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Affiliation(s)
- Michel W Coppieters
- Department of Physiotherapy, School of Health and Rehabilitation Sciences, The University of Queensland, Australia.
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Ander DS, Aisiku IP, Ratcliff JJ, Todd KH, Gotsch K. Measuring the Dyspnea of Decompensated Heart Failure With a Visual Analog Scale: How Much Improvement Is Meaningful? ACTA ACUST UNITED AC 2004; 10:188-91. [PMID: 15314477 DOI: 10.1111/j.1527-5299.2004.03475.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Patients presenting to the emergency department with heart failure are evaluated based on the subjective sensation of dyspnea. In this study, the authors sought to determine the change in dyspnea, measured by a visual analog scale (VAS), which is associated with a meaningful change in the patient's perception and the effect of dyspnea severity on the VAS. In this prospective, observational study the authors defined a meaningful change in VAS dyspnea as the difference between VAS scores when patients reported "a little less difficulty breathing" or "a little more difficulty breathing." Seventy-four patients were evaluated, and the mean for a meaningful change in VAS was 21.1 mm (95% confidence interval, 12.3-29.9 mm). Patients that recorded higher index VAS scores had a significantly greater change in VAS. VAS scores and the changes with treatment provide the treating physician with another means to assess the effects of their interventions.
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Affiliation(s)
- Douglas S Ander
- Department of Emergency Medicine, Emory University, Atlanta, GA, USA.
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